1886 |
2023-10-31 15:53 |
Anonymous (not verified) |
94.188.205.176 |
CEM Businesses LLC |
Limited Liability Company |
608 Evergreen Cir Nw Bondurant, IA 50035 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-10-31 |
Dane McDonald |
dane.mcdonald@stellar-solar.net |
Bondurant |
Polk |
Iowa |
Raelynn Aicher |
Cameron VanBuren |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dane McDonald |
dane.mcdonald@stellar-solar.net |
Self |
Bondurant |
Polk |
Iowa |
Raelynn Aicher |
Cameron VanBuren |
Signed |
1885 |
2023-10-29 08:05 |
Anonymous (not verified) |
94.188.207.223 |
MB Radon Services |
Limited Liability Company |
13206 State Hwy 2, Lamoni, Iowa, 50140 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-10-29 |
Kyle Ramaeker |
raymaker83@gmail.com |
LAMONI |
IA |
United States |
Adam Boge |
Lance Webster |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kyle Ramaeker |
raymaker83@gmail.com |
Owner/Operator |
LAMONI |
IA |
United States |
Adam Boge |
Lance Webster |
Signed |
1884 |
2023-10-27 18:32 |
Anonymous (not verified) |
94.188.205.177 |
J&M dry wall |
Proprietorship |
948 Kern St |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-10-27 |
Melecio Zacarias-Cano |
Meleciozacarias29@gmail.com |
Waterloo |
Black hawk |
IA |
Luis flores |
Luis flores |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Melecio Zacarias-Cano |
Meleciozacarias29@gmail.com |
Self |
Waterloo |
Black hawk |
IA |
Luis Flores |
Luis flores |
Signed |
1883 |
2023-10-27 10:49 |
Anonymous (not verified) |
94.188.207.228 |
Ron's SIding and Construction |
Proprietorship |
6097 26th Ave |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-10-27 |
Ron Heggebo |
heggebojessica@yahoo.com |
Vinton |
Benton |
IA |
Jessica Heggebo |
Jessica Heggebo |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ron Heggebo |
heggebojessica@yahoo.com |
Self |
Vinton |
Benton |
IA |
Jessica Heggebo |
Jessica Heggebo |
Signed |
1882 |
2023-10-27 10:40 |
Anonymous (not verified) |
94.188.205.166 |
Ron's SIding and Construction |
Proprietorship |
6097 26th Ave |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2025-02-02 |
Ron Heggebo |
heggebojessica@yahoo.com |
Vinton |
Benton |
IA |
Jessica Heggebo |
Jessica Heggebo |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ronnie Heggebo |
heggebojessica@yahoo.com |
self |
Vinton |
Benton |
IA |
Jessica Heggebo |
Jessica Heggebo |
Signed |
1881 |
2023-10-26 14:10 |
Anonymous (not verified) |
94.188.205.175 |
McAninch Painting LLC |
Limited Liability Company |
2422 Richmond Ave. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-10-26 |
Brian McAninch |
brian@allcoatfinishes.com |
Des Moines |
Polk |
Iowa |
Kane Fairman |
Brad Sandstoe |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brian McAninch |
brian@allcoatfinishes.com |
Self |
Des Moines |
polk |
Iowa |
Kane Fairman |
Brad Sandstoe |
Signed |
1880 |
2023-10-26 13:24 |
Anonymous (not verified) |
94.188.205.167 |
Brown Remodel & Construction LLC |
Limited Liability Company |
7819 Evans St Mingo iowa 50168 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-10-26 |
Matthew Ray Brown |
brownremodel@gmail.com |
Mingo |
Jasper |
Iowa |
Rebecca Lynn Brown |
Michael Moore |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Matthew Ray Brown |
brownremodel@gmail.com |
Self |
Mingo |
Jasper |
Iowa |
Rebecca lynn Brown |
Michael Moore |
Signed |
1879 |
2023-10-26 13:17 |
Anonymous (not verified) |
94.188.207.224 |
CR Exteriors |
Proprietorship |
1636 Parktown Ct NE Unit 9 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-10-26 |
corey becker |
cab222.ab@gmail.com |
cedar rapids |
linn |
iowa |
Brian Ashlock |
Brian Coover |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Corey Becker |
cab222.ab@gmail.com |
same |
Cedar Rapids |
Linn |
Iowa |
Brian Ashlock |
Brian Coover |
Signed |
1878 |
2023-10-26 09:06 |
Anonymous (not verified) |
94.188.205.168 |
Jones Facility Maintenance |
Limited Liability Company |
3929 Council Street NE |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-10-25 |
Mason Jones |
jonesmason546@gmail.com |
Cedar Rapids |
IA |
United States |
Lindsey Jones |
Seth Wennermark |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mason Bradley Jones |
jonesmason546@gmail.com |
Owner |
Cedar Rapids |
IA |
United States |
Lindsey Jones |
Seth Wennermark |
Signed |
1877 |
2023-10-23 15:49 |
Anonymous (not verified) |
94.188.207.228 |
Craig Michael Wilson |
Proprietorship |
24538 118th Street, Columbus Junction, IA 52738 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-10-16 |
Craig Michael Wilson |
tripod109@hotmail.com |
Columbus Junction |
Louisa |
IA |
Brenda Wilson |
Ruger Dean |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Craig Michael Wilson |
tripod109@hotmail.com |
Self |
Columbus Junction |
Louisa |
IA |
Brenda Wilson |
Ruger Dean |
Signed |
1876 |
2023-10-23 14:26 |
Anonymous (not verified) |
94.188.205.169 |
Magnus, LLC |
Limited Liability Company |
1120 2nd Street SE |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-10-23 |
Kristina Link |
magnina@aol.com |
Cedar Rapids |
IA |
IA |
Shannon Thompson |
Jeff Spies |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kristina Link |
magnina@aol.com |
business owner |
Cedar Rapids |
Iowa |
Iowa |
Shannon Thompson |
Jeff Spies |
Signed |
1875 |
2023-10-23 11:34 |
Anonymous (not verified) |
94.188.205.176 |
Makers Blinds LLC |
Limited Liability Company |
3220 44Th St Des Moines, IA 50310 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-10-23 |
Ryan Seiler |
makersblinds@gmail.com |
Des Moines |
Polk |
Iowa |
Jon Buller |
Terry Miles |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ryan Seiler |
makersblinds@gmail.com |
Manager |
Des Moines |
Polk |
Iowa |
Jon Buller |
Terry Miles |
Signed |
1874 |
2023-10-22 11:54 |
Anonymous (not verified) |
94.188.205.166 |
Midwest UAV LLC |
Limited Liability Company |
1400 15th St SE Bondurant Iowa 50035 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-10-22 |
Kaleb Thomas Trammell |
kttrammell05@gmail.com |
Bondurant |
Polk |
IA |
Alan Willis |
Danielle Trammell |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kaleb Thomas Trammell |
kttrammell05@gmail.com |
Owner |
Bondurant |
Polk |
IA |
Alan Willis |
Danielle Trammell |
Signed |
1873 |
2023-10-20 09:25 |
Anonymous (not verified) |
94.188.207.228 |
GC Hauling LLC |
Limited Liability Company |
310 North 18th Street, Indianola, IA, 50125 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-10-20 |
Garrett Joseph Claerhout |
gjclaerhout@hotmail.com |
INDIANOLA |
IA |
IA |
Kirsten Claerhout |
Jay Claerhout |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Garrett Joseph Claerhout |
gjclaerhout@hotmail.com |
Same Person |
INDIANOLA |
IA |
IA |
Kirsten Claerhout |
Jay Claerhout |
Signed |
1872 |
2023-10-18 10:59 |
Anonymous (not verified) |
94.188.205.177 |
Derik Gonyier |
Proprietorship |
1421 Chicago Ave, Savanna, IL 61074 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-10-14 |
Derik Ray Gonyier |
deriknalexis121413@gmail.com |
Savanna |
Carroll |
IL |
Kyle Lee Sturtz |
Daryl Eugene Gonyier |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Derik Ray Gonyier |
deriknalexis121413@gmail.com |
Self |
Savanna |
Carroll |
IL |
Kyle Lee Sturtz |
Daryl Eugene Gonyier |
Signed |
1871 |
2023-10-18 10:27 |
Anonymous (not verified) |
94.188.205.169 |
Derik Gonyier |
Proprietorship |
1421 Chicago Ave, Savanna, IL 61074 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-10-14 |
Derik Ray Gonyier |
deriknalexis121413@gmail.com |
Savanna |
Carroll |
IL |
Kyle Lee Sturtz |
Daryl Gonyier |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Derik Ray Gonyier |
deriknalexis121413@gmail.com |
Self |
Savanna |
Carroll |
IL |
Kylee Lee |
Daryl Eugene Gonyier |
Signed |
1870 |
2023-10-17 16:13 |
Anonymous (not verified) |
94.188.205.176 |
Diamond ridge |
Proprietorship |
1842 Glenwood cir Des Moines Iowa 50320 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-10-17 |
Marianna Landeros |
cheri6876@yahoo.com |
Des moines |
Polk |
Iowa |
Marianna Landeros |
Cheri Martinez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Marianna Landeros |
landerosmary@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
Cheri Martinez |
Jessica Newton |
Signed |
1869 |
2023-10-17 00:59 |
Anonymous (not verified) |
94.188.207.230 |
Lisa's Janitorial |
Limited Liability Company |
406 S. 10th Street Sac City, Iowa 50583 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-10-16 |
Bruce Homer |
bhjhomer69@gmail.com |
Sac City |
Sac |
Iowa |
Autumn Simonsen |
Misty Brewster |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bruce Homer |
bhjhomer69@gmail.com |
Self |
Sac City |
Sac |
Iowa |
Autumn Simonsen |
Misty Brewster |
Signed |
1868 |
2023-10-16 12:36 |
Anonymous (not verified) |
94.188.205.177 |
North Bay Dock Service, LLC |
Limited Liability Company |
PO Box 374, Spirit Lake, IA 51360 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-10-16 |
Teresa A. JOhnson |
NBDSLLC@gmail.com |
Spirit Lake |
Dickinson |
Iowa |
Michael Chozen |
April Bosma |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Teresa Johnson |
NBDSLLC@gmail.com |
Manager |
Spirit Lake |
Dickinson |
Iowa |
Michael Chozen |
April Bosma |
Signed |
1867 |
2023-10-16 12:34 |
Anonymous (not verified) |
94.188.205.176 |
North Bay Dock Service |
Proprietorship |
PO Box 374, Spirit Lake, IA 51360 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-10-16 |
Donald L. Johnson, Jr. |
djtjaj@outlook.com |
Spirit Lake |
Dickinson |
Iowa |
Michael Chozen |
April Bosma |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Teresa Johnson |
djtjaj@outlook.com |
bookkeeper |
Spirit Lake |
Dickinson |
Iowa |
Michael Chozen |
April Bosma |
Signed |
1866 |
2023-10-11 08:17 |
Anonymous (not verified) |
94.188.205.177 |
Wilson's Window Tinting |
Limited Liability Company |
385 South Stewart Street North Liberty, Iowa 52317 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-10-07 |
Wilson Paiva |
wilsonswindowtinting@gmail.com |
North Liberty |
IA |
United States |
John W. Helscher |
Jose Omar Paz |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Wilson Paiva |
wilsonswindowtinting@gmail.com |
Owner |
North Liberty |
IA |
United States |
John Helscher |
Jose Omar Paz |
Signed |
1865 |
2023-10-09 10:28 |
Anonymous (not verified) |
94.188.205.166 |
Lori Martinez |
Proprietorship |
6650 SE 5 TH STREET DES MOINES IA, 50315 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-10-09 |
Lori Martinez |
azulbenavidez04@gmail.com |
Des Moines |
Polk |
Iowa |
R. Mitch Coluzzi |
Jennifer Lambert |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lori Martinez |
azulbenavidez04@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
R. Mitch Coluzzi |
Jennifer Lambert |
Signed |
1864 |
2023-10-09 09:52 |
Anonymous (not verified) |
94.188.207.223 |
Admiral Staffing Inc |
Limited Liability Company |
580 8th Ave, 15th Floor, New York NY 10018 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-10-09 |
Rezwan Rafeek |
ray@admiralstaffinginc.com |
23 Catalpa Lane |
Valley Stream |
NY |
Ikbal Sherif |
Salim Balee |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Shafi Rafeek |
shafi@admiralstaffinginc.com |
Office Manager |
New York |
NY |
United States |
Ikbal Sherif |
Salin Balee |
Signed |
1863 |
2023-10-06 12:24 |
Anonymous (not verified) |
94.188.207.223 |
ADRIAN CAZARES HERNANDEZ |
Proprietorship |
409 N 16TH PL, ESTHERVILLE, IA 51334 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-10-06 |
ADRIAN CAZARES HERNANDEZ |
JOEL@WALKERINSURANCE.COM |
ESTHERVILLE |
EMMET |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
ADRIAN CAZARES HERNANDEZ |
JOEL@WALKERINSURANCEIA.COM |
SELF |
ESTHERVILLE |
EMMET |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
1862 |
2023-10-05 14:30 |
Anonymous (not verified) |
94.188.207.225 |
J trinidad Garcia Ferrer |
Proprietorship |
3722 SE 14th St Apt 9 Des Moines, Iowa 50320 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-10-01 |
J Trinidad Garcia Ferrer |
deb@piciowa.com |
Des Moines |
Polk |
Iowa |
Deb Stratton |
Martin Pinon |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
J trinidad Garcia Ferrer |
deb@piciowa.com |
self |
Des Moines |
Polk |
IOwa |
Deb Stratton |
Martin Pinon |
Signed |
1861 |
2023-10-05 10:14 |
Anonymous (not verified) |
94.188.207.227 |
Charles von Maur |
Proprietorship |
18325 Robbins Road Pleasant Valley IA 52767 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-10-05 |
Charles von Maur |
rlarsen@vonmaur.com |
Pleasant Valley |
Scott |
IA |
Robert L Larsen |
Amanda Bratthauer |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Robert L Larsen |
rlarsen@vonmaur.com |
Outside consultant |
east moline |
Rock Island |
IL |
Josh Barnes |
Amanda Bratthauer |
Signed |
1860 |
2023-10-04 14:31 |
Anonymous (not verified) |
94.188.207.229 |
Raymond Osbon |
Proprietorship |
1634 Park Towne LN NE |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-10-04 |
Raymond Earl Osbon |
rozbon999@gmail.com |
Cedar Rapids |
Linn |
Iowa |
Brandon Gibbs |
Jamie Fisher |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Raymond Earl Osbon |
rozbon999@gmail.com |
Myself |
Cedar Rapids |
Linn |
Iowa |
Brandon Gibbs |
Jamie Fisher |
Signed |
1859 |
2023-10-04 07:54 |
Anonymous (not verified) |
94.188.205.167 |
Pacheco Constructrion |
Limited Liability Company |
1614 Center Street, Des Moines IA 50314 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-10-04 |
Ulises Pacheco |
info@pachecoconstruction.com |
Des Moines |
Polk |
Iowa |
Melissa Gray |
Darci Rene Pacheco |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ulises Pacheco |
info@pachecoconstruction.com |
Self |
Des Moines |
Polk |
Iowa |
Melissa Gray |
Darci Rene Pacheco |
Signed |
1858 |
2023-10-03 13:29 |
Anonymous (not verified) |
94.188.207.223 |
Quad city drywall Solutions LLC |
Limited Liability Company |
5804 n thornwood ave Davenport iowa |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-10-03 |
Erivan Emmanuel Montalvo Delcompare |
montalvobills6@gmail.com |
Davenport |
Scott |
Iowa |
Natalia Ann Montalvo |
Juan Portela |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Erivan Emmanuel Montalvo Delcompare |
montalvobills6@gmail.com |
Owner |
Davenport |
Scott |
Iowa |
Natalia Montalvo |
Juan Portela |
Signed |
1857 |
2023-10-02 16:33 |
Anonymous (not verified) |
94.188.205.169 |
Noah Blount |
Proprietorship |
2611 capitol ave, Des Moines, IA 50317, United States |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-10-02 |
Noah Blount |
nbeav5@gmail.com |
Des Moines |
Des Moines |
Iowa |
Jordan Loyd |
Charles Woods |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jordan Nisiewicz |
jnisiewicz@leafhome.com |
Recruiter |
Kansas City |
Jackson |
Missouri |
Jordan Loyd |
Charles Woods |
Signed |
1856 |
2023-09-29 13:18 |
Anonymous (not verified) |
94.188.205.166 |
MUESSIGMANN ENTERTAINMENT LLC |
Limited Liability Company |
906 2ND AVE SE SPENCER IA 51301 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-09-27 |
JON MUESSIGMANN |
MUESSIGMANNENT@GMAIL.COM |
SPENCER |
CLAY |
Iowa |
TAMI KLEIN |
JENNIFER YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
JON MUESSIGMANN |
MUESSIGMANNENT@GMAIL.COM |
SELF |
SPENCER |
CLAY |
Iowa |
TAMI KLEIN |
JENNIFER YOUNGWIRTH |
Signed |
1855 |
2023-09-27 12:56 |
Anonymous (not verified) |
94.188.207.224 |
Lincoln Hotel Group |
Limited Liability Company |
9240 Andermatt Drive Suite 1 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-09-27 |
John Edward Klimpel |
jklimpel@lincolnhotelgroup.com |
Lincoln |
Lancaster |
NE |
Carrie A. Fleck |
Jill N. Korta |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brent Besch |
brent.besch@marshmma.com |
Client |
Lincoln |
Nebraska |
NE |
Carrie A Fleck |
Jill N Korta |
Signed |
1854 |
2023-09-27 11:22 |
Anonymous (not verified) |
94.188.205.174 |
Wen Boatwright |
Proprietorship |
4200 Indianola Ave Des Moines, IA 50320 United States |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-09-27 |
Wen Boatwright |
wenboatwrght@gmail.com |
Des Moines |
Des Moines |
Iowa |
Jordan Nisiewicz |
Cody Dunbar |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Jordan Nisiewicz |
jnisiewicz@leafhome.com |
Recruiter |
Kansas City |
Johnson |
Missouri |
Jordan Loyd |
Cody Dunbar |
Signed |
1853 |
2023-09-26 10:16 |
Anonymous (not verified) |
94.188.205.177 |
Saketh Mahavadi |
Limited Liability Company |
294 s 83rd street |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-09-26 |
Saisaketh |
sakethmahavadi@gmail.com |
West Des Moines |
IA |
United States |
David Chan |
Ahnaf Yeasin |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
David Chan |
Davidchan8873@gmail.com |
Business Partner |
West Des Moines |
IA |
United States |
Saketh Mahavadi |
Ahnaf Yeasin |
Signed |
1852 |
2023-09-24 16:02 |
Anonymous (not verified) |
94.188.205.174 |
Handy Andy Enterprises LLC |
Limited Liability Company |
PO Box 479, Williamsburg, Iowa 52361 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-01-01 |
Andrew J Garner |
andy@handyandyenterprises.net |
Williamsburg |
Iowa |
Iowa |
Amanda Bowen |
Kent Pope |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Andrew J Garner |
agarner6977@gmail.com |
Owner |
Williamsburg |
Iowa |
Iowa |
Amanda Bowen |
Kent Pope |
Signed |
1851 |
2023-09-22 12:36 |
Anonymous (not verified) |
94.188.207.229 |
MNM Construction |
Proprietorship |
3224 sw 12th place des moines iowa 50315 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-09-22 |
craig allen mccormick |
craigmccormick.6363@gmail.com |
Des Moines |
Iowa |
Iowa |
Tara Murphy |
Kristie Hubbard |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
craig mccormick |
craigmccormick.6363@gmail.com |
self |
Des Moines |
Iowa |
Iowa |
Tara Murphy |
Kristie Hubbard |
Signed |
1850 |
2023-09-20 16:28 |
Anonymous (not verified) |
94.188.207.225 |
JB DOCK SERVICE |
Limited Liability Company |
1313 34TH ST SPIRIT LAKE, IA 51360 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-09-20 |
JONATHON BRUNSVOLD |
jbdockservice@gmail.com |
SPIRIT LAKE |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
JONATHON BRUNSVOLD |
jbdockservice@gmail.com |
SELF |
SPIRIT LAKE |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
1849 |
2023-09-19 14:57 |
Anonymous (not verified) |
94.188.207.228 |
Iowa painting solutions llc |
Limited Liability Company |
2500 pleasant st |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-09-19 |
Patricia Davalos |
iowapaintingsolutionsllc@gmail.com |
Des Moines |
Polk |
Iowa |
Javier Rascon |
Angel Perez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Iowa painting solutions llc |
iowapaintingsolutionsllc@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Javier Rascon |
Angel Perez |
Signed |
1848 |
2023-09-19 10:20 |
Anonymous (not verified) |
94.188.207.226 |
Josh Woodworth |
Proprietorship |
16405 u.s. 67 milan il 61264 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-09-19 |
Josh woodworth |
joshwoodworth84@live.com |
milan |
Rock island |
Illinois |
Cody dunbar |
Jordan nisiewicz |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cody dunbar |
cdunbar@leaffilter.com |
Install manager |
moline |
Rock island |
illinois |
Cody dunbar |
Jordan nisiewic |
Signed |
1847 |
2023-09-18 18:20 |
Anonymous (not verified) |
94.188.205.168 |
William O'Brien |
Proprietorship |
1069 Yukon Ave Sumner Iowa 50674 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-09-18 |
William Charles O'Brien |
wcobrien63@gmail.com |
Sumner |
Bremer |
Iowa |
Patrick B Dillon |
Christina Rader |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
William Charles O'Brien |
wcobrien63@gmail.com |
self |
Sumner |
Bremer |
Iowa |
Patrick B Dillon |
Christina Rader |
Signed |
1846 |
2023-09-15 13:25 |
Anonymous (not verified) |
94.188.207.224 |
Kg Roofing |
Limited Liability Company |
1820 1 Ave S, Fort Dodge IA 50501 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2023-09-15 |
Tyler Price |
tylerprice636@gmail.com |
Fort Dodge |
Webster |
IOWA |
Ashley Bates |
Breann Moore |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Tyler |
tylerprice636@gmail.com |
Self |
Fort Dodge |
Webster |
IOWA |
Ashley Bates |
Breann Moore |
Signed |
1845 |
2023-09-15 11:31 |
Anonymous (not verified) |
94.188.205.174 |
Penny Carlton |
Limited Liability Company |
2550 Middle Rd. Suite 300 Bettendorf, IA. 52722 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-09-15 |
Penny Marie Carlton |
thrivecounselingqc@gmail.com |
Bettendorf |
Scott |
Iowa |
Anna Blanchard |
Nick Carlton |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Penny Carlton |
thrivecounselingqc@gmail.com |
self, owner |
Bettendorf |
Scott |
Iowa |
Katie Flynn |
Nick Carlton |
Signed |
1844 |
2023-09-14 14:15 |
Anonymous (not verified) |
94.188.205.177 |
Royal Gutters & Construction, LLC |
Limited Liability Company |
1420 120th Street, Hazleton, IA 50641 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-04-01 |
Andy Hershberger |
hershbergera@gmail.com |
Hazleton |
Buchanan |
Iowa |
Eli Raber |
Steve Frost |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Andy Herschberger |
hershbergera@gmail.com |
self |
Hazleton |
Buchanan |
Iowa |
Eli Miller |
Steve Frost |
Signed |
1843 |
2023-09-14 14:12 |
Anonymous (not verified) |
94.188.205.167 |
Rosenbum Construction, LLC |
Limited Liability Company |
720 South Street, Arlington, Iowa 50606 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-09-02 |
Thomas Rosenbum |
tomdolly1126@yahoo.com |
Arlington |
Fayette |
Iowa |
Dolly Rosenbum |
Steve Frost |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Thomas Rosenbum |
tomdolly1126@yahoo.com |
Self |
Arlington |
Fayette |
Iowa |
Dolly Rosenbum |
Steve Frost |
Signed |
1842 |
2023-09-14 14:08 |
Anonymous (not verified) |
94.188.205.174 |
RM Construction |
Limited Liability Company |
1623 120th Street, Hazleton, IA |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-09-14 |
Roy Miller |
roymiller@aol.com |
Hazleton |
Buchanan |
Iowa |
Steve Frost |
Julie Schick |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Roy Miller |
roymiller@aol.com |
self |
Hazleton |
Buchanan |
Iowa |
Steve Frost |
Julie Schick |
Signed |
1841 |
2023-09-14 13:52 |
Anonymous (not verified) |
94.188.207.225 |
Double M Construction LLC |
Limited Liability Company |
3886 Diamond Rd, Elgin, IA 52141 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-05-16 |
Eli Miller |
elimiller@gmail.com |
Iowa |
Fayette |
Iowa |
Julie Schick |
Kelly Matt |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Eli Miller |
elimiller@gmail.com |
self |
Elgin |
Fayette |
Iowa |
Julie Schick |
Kelly Matt |
Signed |
1840 |
2023-09-14 13:48 |
Anonymous (not verified) |
94.188.207.228 |
L.R. Construction, LLC |
Limited Liability Company |
1564 110th Street, Hazleton, IA 50641 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-02-23 |
Levi R Raber |
amish@amish.com |
Hazleton |
Buchanan |
Iowa |
Mary Ann Raber |
Daniel Raber |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Levi R Raber |
amish@amish.com |
self |
Hazleton |
BUCHANAN |
Iowa |
Mary Ann Raber |
Daniel Raber |
Signed |
1839 |
2023-09-12 11:22 |
Anonymous (not verified) |
94.188.205.167 |
J.S. Reeves Consulting LLC |
Limited Liability Company |
1610 1st Ave, Perry, IA 50220 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-09-12 |
joni Sue Reeves |
jonisreeves@att.net |
Perry |
IA |
United States |
Maggie Rhodes |
Barb Butler |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joni Sue Reeves |
jsreeves67@gmail.com |
Same |
Perry |
IA |
United States |
Maggie Rhodes |
Barb Butler |
Signed |
1838 |
2023-09-12 10:48 |
Anonymous (not verified) |
94.188.207.224 |
OKOBOJI TSHIRT CENTER LLC |
Limited Liability Company |
PO BOX 158 ARNOLDS PARK, IA 51331 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-09-12 |
ADIR SEBAN |
PACIFIC513@YAHOO.COM |
ARNOLDS PARK |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
ADIR SEBAN |
PACIFIC513@YAHOO.COM |
SELF |
ARNOLDS PARK |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
1837 |
2023-09-11 19:10 |
Anonymous (not verified) |
94.188.207.230 |
TBA Handyman service |
Limited Liability Company |
619 e 10th st. north newton Iowa 50208 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-09-11 |
Joey Conkling |
tba050402@gmail.com |
newton |
jasper |
Iowa |
Ashton tyler conkling |
Bianca Storm Conkling |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
TBA Handyman Service |
tbaconstruction02@gmail.com |
self |
newton |
jasper |
iowa |
Ashton tyler Conkling |
Bianca Storm Conkling |
Signed |